patient guide for hips - wales.nhs.uk · patient guide for hips ... management of pain following...

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in partnership with

Patient Guide for Hips Before, during and after joint replacement

Please bring this guide book

with you each time you visit

Supporting your Enhanced Recovery

2 Prince Philip Hospital and Glangwili Hospital

3Your booking information

This guide book belongs to: Your surgery date:

Addressograph

Ticket to go home...

Preoperative assessment date:

Joint school date:

Date of surgery:

Expected date of discharge:

We expect you to go home on:

Who is going to take you home:

Telephone number of person

taking you home:

Follow up clinic appointment:

Prince Philip Hospital and Glangwili Hospital 3

3Hospital contact Telephone List

Pre-Admission clinic Prince Philip Hospital Llanelli 01554 783717

Pre-Admission clinic Glangwili Hospital Carmarthen 01267 227186

Ward 6 Prince Philip Hospital 01554 783108 01554 783109

Cothi Ward Glangwili Hospital 01267 227125

Orthopaedic Specialist Nurse 01554 783321

Physiotherapy Prince Philip Hospital, Llanelli 01554 783204

Physiotherapy Glangwili Hospital, Carmarthen 01267 227740

Occupational Therapy Prince Philip Hospital, Llanelli 01554 783205

Occupational Therapy Glangwili Hospital, Carmarthen 01267 227719

Please nominate one family member to liaise with the ward for patientinformation as this releases the nurses to care for your relative moreeffectively.

Visiting Times

The visiting hours at Ward 6 Prince Philip hospital are 7-8pm Monday to Friday. On Bank holidays and weekends it is 2.30-3.30 and 7-8pm. In Cothi Ward Glangwili Hospital Carmarthen it is 7-8.30pm Monday to Friday and weekends 2-7pm.

There may be circumstances when relatives/friends cannot visit during these hours, please do not worry; please ring and discuss with the nurse in charge prior to visiting outside of these times.

You will find it useful to bring this guide book with you each time you visit Prince Philip Hospital and Glangwili Hospital.


33Hip Guide Book

1 Welcome to Enhanced Recovery 6

2 Introduction A guide to Prince Philip Hospital and

Glangwili Hospital services7

General Information 9

3 Educational

information

Total hip replacement 11

Anaesthesia and you 14

Management of pain following your surgery 16

Pharmacy department 19

Blood transfusion 20

Reducing the risk of infection in hospital 21

4 Preparation

for your

hospital stay

Pre admission assessment clinic 22Contact between patients, their relatives

and friends 26Activity guidelines pre and post-op exercises

and goals 27

5 Hospital stay Day of surgery 31

What to expect – immediately after surgery 31


33 Contents

6 Discharge

planning

Preparing to leave the hospital for home 36

Following your stay 36

Advice/precautions for daily activities 36

Getting in and out of bed 38

7 Frequently asked questions 42

8 Your diary

and notes

Your diary 44

Keep-in touch list 45

Your questions and comments page 46

Complaints and Compliments 47


31 Welcome to Enhanced Recovery

Enhanced Recovery is a partnership between you and Hywel Dda Health Board. The aim of the partnership is to ensure you know what to expect and you are fully prepared for your joint replacement surgery. This will enable you to make a speedy recovery and aim for you to return to the activities you enjoy when safe to do so. It is essential that you participate in your care, to achieve the best possible outcome after your operation. This patient guide is a vital part of the partnership and we strongly encourage you to read it and to bring it with you when you are admitted to the orthopaedic department for your surgery. If you need clarification or have questions for which you are unable to find the answers please do not hesitate to contact a member of the team.

We strive to provide high quality treatment and patient centred care

for those who require elective orthopaedic surgery in a positive,

caring environment.


32 Introduction

A Guide to Prince Philip Hospital and Glangwili

Hospital and the Services it Provides

The Orthopaedic Service within Carmarthenshire consists of two designated units for the treatment and care of patients requiring joint replacements. The ward area in Prince Phillip Hospital Llanelli is ward 6 and at Glangwili Hospital Carmarthen is Cothi ward. The Orthopaedic team consists of 10 Consultant surgeons each has sub-specialist skills and are committed to providing a high standard of orthopaedic care. The team is supported by dedicated anaesthetic consultants. They have specialist skills in anaesthetising patients undergoing joint replacement surgery. Other important members of the team include medical Staff, Pre-admission nurses, Specialist Nurses, Theatre staff, Physiotherapist, Occupational Therapist, Ward Nurses and other support staff.


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Prince Philip Hospital and Glangwili Hospital Patient Questionnaire

As a Health Board we aim to assess all patients’ health and quality of life before and after surgery. This allows us to assess the effectiveness of the operation and therefore improve the outcomes for patients. This is called PROMS (Patient Reported Outcome Measures) you will be asked to fill in a short questionnaire at the Pre-Admission clinic and another following surgery this may be done at the outpatient clinic or you will be contacted by a member of the team to complete the questionnaire over the telephone.

Giving your informed consent

Before a doctor or other health professional examines or treats you, they need your consent. Sometimes you can simply tell them whether you agree with their suggestions. However, sometimes a written record of your decision may be needed. You will then be asked to sign a consent form.

Before you give your consent the health professionals looking after you must ensure you know enough to enable you to decide about treatment. It is up to you to choose whether or not to consent to what is being proposed. Always ask as many questions as you like. As well as giving you information, health professionals must listen and do their best to answer your questions. As a reminder, you can write your questions down. The person you ask should do his or her best to answer, but if they do not know they should find someone else who is able to discuss your concerns.

More information on consent is available in the Health Board leaflet ‘About the Consent Form: Information for Patients’. Please feel free to ask for a copy.

Data Protection Act

Under the Data Protection Act 1998, we are committed to protecting the privacy of patient information. You have the right to view medical records held by Hywel Dda Health Board. If you or your representative wish to have access to your medical records or have copies made there is a charge for this. Please note that the final permission for access lies with the relevant Consultant/Consultants.


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Chaperone

You have the right to have a chaperone provided by the hospital, during any examination and certain procedures. You may choose a family member or close friend or carer. You also have a right to choose a carer to be involved in your care.

Smoking

Hywel Dda Health Board has a No Smoking policy with which we request your cooperation. Smoking is actively discouraged particularly before your operation as this can increase your risk of complications after surgery. You may find it helpful to discuss giving up smoking or Nicotine replacement therapy with your GP, Practice Nurse or at the Pre Admission clinic.

Dietary requirements

Eating a good healthy balanced diet helps you feel well and stay well. If you have any special dietary requirements please inform the Pre Admission nurses who will inform the ward. The nurses will also ask you some questions about your usual eating habits as well as recording your height and weight. This allows the nurses to offer you advice on how to optimise your weight or diet prior to surgery.

Mobile phones

We would request that you and your visitors do not bring mobile phones into the hospital, as they can disturb other patients.

Risk management

There is a comprehensive risk management process in place, which ensures that patient safety is assured and that areas of improvement are identified and an improvement plan implemented.

Manual Handling PolicyThe Health Board operates a Non-Lifting Policy. Staff are available to assist you with your mobility needs and are trained in the use of equipment if it is required. Please ask if you require any assistance.


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Fire routineThe fire alarm is tested between 8-9am on a Wednesday. All the staff in your ward have done fire training and are aware of the procedure to be followed if the alarm does sound outside the test time.

Unacceptable Behaviour

Our staff deserve the right to do their jobs without being verbally or physically abused. Most of our patients and visitors respect this right. Thank you for being one of them. We will work with the police to prosecute those who continue to abuse our staff.


3 Educational information

Total hip replacement

The artificial joint

The artificial joint, or prosthesis, can be made of metal alloy, ceramic and polyethylene plastic. Some prostheses are secured in the bone with bone cement, whereas others have a special coating (hydroxyapatite), which binds with the bone and does not require cement or fixation.

Why do I need a hip replacement?

Because you may have significant pain which makes it difficult or impossible to carry out normal daily activities. You are restricted in how far you can walk and may have to use a stick. Stairs can be very difficult. Your hip is becoming stiff and you cannot put your shoes and socks on easily. You may be having difficulty sleeping due to pain.

The operation

The operation usually takes between 1-2 hours. You will be in hospital for 3-5 days. You should be prepared to work hard at the exercises given to you by the therapy staff. The majority of patients tell us that they are pleased with the result of their hip replacement. Some however, are less satisfied either because a complication has arisen or their expectations are too high. Total rejuvenation is not achievable!

Complications

It should be remembered that most operations are performed without incident.

However, all operations carry some risks and although everything is done to keep such risks to a minimum, you should be aware of what the risks are before agreeing to have an operation, see the following two pages:

Xray of hip showing

OsteoarthritisXray of hip showing

total hip replacement


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Blood clotsBlood clots in leg veins (Deep Vein Thrombosis or DVT) or in the lungs (Pulmonary Embolus or PE) can occur in a few patients. This can be life threatening, but the risk is very low. Measures that are taken to reduce the risk are the use of foot pumps and elastic stockings, blood thinning injections or tablets and early mobilisation.

Delayed wound healingFluid may ooze from the wound or drain site before full healing has occurred and at times may be treated with antibiotics. A collection of blood (haematoma) may occasionally form deep in the wound. It usually disperses spontaneously but may need to be removed by operation. Deep infection, although uncommon (less than 1%), is a serious problem and may lead to further surgery. However, antibiotics are routinely used in every hip replacement and the operation is performed under sterile conditions.

DislocationOccasionally the ball of the joint may dislocate from the socket (1-3% of patients). This is a greater risk in the early days soon after the operation before the tissues around the joint have healed and made a strong scar. To reduce this risk you must follow our advice and precautions for daily activities which is explained later in this guide. Dislocation requires a manipulation under anaesthetic to realign the joint. Occasionally, dislocation may happen years after surgery if the joint has become very worn or loose.

Joint replacement wear95% of the modern hip replacements will last from 10-15 years but all joints wear with time and become loose and painful. Body weight and levels of activity are two factors that affect rate of wear.

Leg length differenceThe surgeon will try to ensure that your legs are of equal length but cannot guarantee this. In some cases the leg must be lengthened in order to stabilise the hip to reduce the risk of dislocation. Most patients do not notice any great difference after their hip replacement. A heel raise can treat any minor leg length difference.


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MortalityJoint replacement surgery carries a mortality risk of 0.4%. Death is usually the result of an unexpected heart attack or stroke or a large pulmonary embolus.

Nerve damageVery occasionally one of the nerves supplying the leg is stretched and does not function properly for a period of time. The most common effect of this is to cause a foot drop. Over 90% of these nerve injuries recover on their own without the need for further surgery.

PainThere is usually some pain related to a major operation but modern methods of pain control mean we are able to keep it to a minimum. Management of pain following your surgery is explained later in this section.


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Anaesthesia and you

What types of anaesthesia are available?

Decisions regarding your anaesthesia are tailored to your personal needs. The types available for you are:

General AnaesthesiaA general anaesthetic gives a state of controlled unconsciousness during which you feel nothing. You will receive n Anaesthetic drugs (an injection or a gas to breathe).n Strong pain relief drugs (morphine or something similar).n Oxygen to breathe.n Sometimes, a drug to relax your muscles.

Regional anaesthesia1. A spinal anaestheticn Local anaesthetic is injected near to the nerves in your back.n You go numb from the waist downwards.n You feel no pain, but you remain conscious.n If you prefer, you can also have drugs which make you feel sleepy and

relaxed (sedation).2. A nerve block

This is an injection of local anaesthetic near to the nerves which go to your leg. Part of your leg should be numb and pain-free for some hours afterwards. You may also not be able to move it properly during this time.

If you are having a general anaesthetic, this injection may be done before the anaesthetic starts, or it may be done when you are unconscious.

A combination of anaestheticsYou can have a spinal anaesthetic and a general anaesthetic together.n You gain the benefits of a spinal anaesthetic but you are unconscious

during the operation.n The general anaesthetic will be ‘lighter’.n Unpleasant after-effects of the general anaesthetic may be less.n You can have a nerve block with a general anaesthetic, or after a

spinal anaesthetic.n This should be more comfortable for you for some hours after the

operation than with a general anaesthetic or spinal anaesthetic alone.


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Will I have any side effects?Your anaesthetist will discuss the risks and benefits associated with the different anaesthetic options, as well as any complications or side effects that can occur with each type of anaesthetic. Nausea or vomiting may be related to anaesthesia or the type of surgical procedure. Although less of a problem today because of improved anaesthetic agents and techniques, these side effects continue to occur for some patients. Medications to treat nausea and vomiting will be given if needed. The amount of discomfort you experience will depend on several factors, especially the type of surgery. Your doctors and nurses can relieve pain with medications. Your discomfort should be tolerable, but do not expect to be totally pain-free. The staff will teach you the pain scale (0-3) to assess your pain level.

What will happen before my surgery?You will meet your anaesthetist immediately before surgery. Your anaesthetist will review all information needed to evaluate your general health. This will include your medical history, laboratory test results, allergies and current medications. With this information, together you will determine the type of anaesthetic best suited for you. He or she will also answer any further questions you may have.

You will also meet your surgical nurses. Preoperative medications may be given, if needed. Once in the anaesthetic room, monitoring devices will be attached such as a blood pressure cuff, ECG and other devices for your safety. At this point, you will be ready for anaesthesia.

During surgery, what does my anaesthetist do?Your anaesthetist is responsible for your comfort and well being before, during and immediately after your surgical procedure. In the operating room, the anaesthetist will manage vital functions, including heart rate and rhythm, blood pressure, body temperature and breathing. The anaesthetist is also responsible for fluid and blood replacement when necessary.

What can I expect after the operation?After surgery, you will be taken to the Recovery Room. You will be watched closely by specially trained nurses. During this period, you may be given extra oxygen and your breathing and heart functions will be observed closely. An anaesthetist is available to provide care as needed for your safe recovery.

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Management of pain following your surgery

Pain following an operation is inevitable, different operations lead to varying degrees of post-operative discomfort and everyone experiences pain differently.

We aim for your pain to be at an acceptable level on movement, and should not prevent appropriate function e.g. Physiotherapy and mobilisation.

Pain control is an essential part of your care

How can we reduce your pain?Pain relief is available in different forms and strengths:

TabletsWhen you are able to drink and eat then you may take your painkillers as a tablet. Most patients will take painkilling tablets after surgery to keep their discomfort to a minimum.

SuppositoriesWhen it is not possible to take tablets by mouth, some painkillers can be given by suppository, which are inserted into the back passage and absorbed by the body.

Nerve blocks and local anaestheticsInjecting anaesthetic into the groin, the spinal region or the operation site blocks nerves carrying painful messages to the brain. This will be carried out at the time of your operation and will give a numbing sensation for 2 to 24 hours, depending on which block is used. The Anaesthetist will discuss this with you.

InjectionYou may need to have painkillers by injection into a muscle in your buttock or upper thigh.

Patient controlled analgesia (PCA)This gives pain relief via a drip. You control this by pressing a demand button allowing a small amount of painkiller into your vein; this usually takes about 5 minutes to start working. The device has a built-in safeguard to prevent you giving yourself too much.


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The nurses and pain team are able to give you advice and support. You can also help to relieve pain by distracting activities e.g. listening to music, reading, watching television, changing position or pillows and relaxation.

Effective pain control is achieved by taking painkillers regularly

Please discuss any concerns with the nurses.

How is pain assessed?After your operation your pain will be assessed regularly, pain will be measured by using a score and you will be asked to describe where the pain fits on a scale of 0 - 3. See following chart.

Pain Score

How would you describe your pain?

0 = no pain

1 = mild pain

2 = moderate pain

3 = severe pain

Pain assessment is necessary to identify, measure and plan your pain relief.

Prevention, or early treatment of pain is far more effective than trying to treat established or severe pain.

Side effectsThese may include nausea and vomiting, constipation, headache, dizziness, feeling sleepy and sometimes mild confusion. These side effects can be reduced with anti-sickness drugs, plenty of fluids, laxatives and rest. Addiction will not occur as the painkillers are being used to relieve your pain.

Please let the nurses know if you feel any of these side effects.

If you are taking other medications or have had a reaction to a medication in the past please let us know.


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When you go homeYou will be prescribed painkillers to take home with you to last for a few days. Continue pain relief as required, take them as directed and do not exceed the stated dose. Further supplies can be obtained from your GP or your local pharmacy.


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Pharmacy Department

What is the role of the pharmacist?

The pharmacy department is responsible for the safe supply and effective use of medicines throughout the hospital. During your hospital stay you will meet several members of the pharmacy team who will be able to help and advise you about your medicines. The Pharmacist works with the consultants and their teams and advises on the appropriate use of medicines. The Pharmacist will visit you during your admission and check your medicine chart to ensure all medicines are prescribed correctly and safely, confirm any allergies or side effects; they will also be able to talk to you about your medication.

Who else works in the pharmacy?The pharmacy technician works with the pharmacist on the ward. They will check any medicines you have brought into hospital and ensure your medicines are in date, suitable for your use in hospital and safely stored, they will also order any additional medication you may need.

Before you come into hospitalDuring your visit to the Pre Admission clinic a nurse will check the medication you are prescribed and tell you if and when you need to discontinue any of your medication prior to surgery. You should bring all your usual medication into hospital with you which will be locked away in a locker by your bed. Please bring all your medication in their original containers rather than decanting them or bringing them in single strips. Please also let us know if you take any herbal or alternative remedies.

Discharge from hospitalThe doctor will prescribe on your drug chart your usual medication and any further drugs that you might need whilst in hospital. These usually consist of anti-sickness medication, antibiotics and analgesia (painkillers). The doctor will prescribe any medication that you require for discharge. Once the prescription is written the Pharmacy Team will prepare your medicines for your discharge and will provide advice on prescribed medications. If you need to continue with the prescribed treatment you will need to order more from your GP before you run out.


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Blood transfusion

Like all medical treatments, a blood transfusion should only be used when really necessary. Blood tests may be done a few weeks before your operation to identify if you have anaemia, which can be treated in advance.

The decision to give a blood transfusion to a patient is made only after careful consideration. In making that decision, your doctor will balance the risk of you having a blood transfusion against the risk of you not having one.

What might I do to reduce my need for blood before an operation?

n Eat a well-balanced diet in the weeks before your operation.

n Boost your iron levels - ask your GP or Consultant for advice, especially if you know that you have suffered from low iron levels in the past.

n If you are on Warfarin or Aspirin, stopping these drugs may reduce the amount of bleeding. You will be informed by the Pre Admission nurses when to stop your medication and if an alternative will be needed prior to your admission.

Blood loss during your surgery is minimised by the use of appropriate medication and anaesthetic techniques.

On the day after your operation, your blood levels will be checked to ensure that you have not become anaemic. Medicines such as iron tablets can help compensate for blood loss. However, if larger amounts of blood are lost, a blood transfusion is the best way of replacing the blood rapidly.


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Reducing the risk of infection in hospital

What you can do to help?

The recent publicity about hospital-acquired infection has caused a great deal of concern across the country. Members of the public have contacted the Infection Control Nurses Association (ICNA) to ask what they can do to reduce the risk of acquiring an infection while they are hospital in-patients, or while they are visiting friends and relatives in hospital. In response to these requests the ICNA has provided the following advice for hospital patients and their visitors.

n Keeping your hands and body clean is important when you are in hospital. Take personal toiletries including soap and a clean flannel with you.

n Taking a container of moist hand wipes with you will ensure you always have some available when you need to clean your hands, for example immediately before you eat a meal.

n Ensure you always wash your hands after using the toilet and if you use a commode do not be afraid to ask for a bowl of water if the nurse does not offer.

n Hospital staff can help protect you by washing their hands, or by cleaning them with special alcohol rub or gel. If a member of staff needs to examine you or perform a procedure, e.g. change your dressing, do not be afraid to ask if they have first washed their hands or used an alcohol rub or gel.

n Try to keep the top of your locker and bed table reasonably free from clutter. Too many things left on top make it more difficult for the cleaning staff to clean your locker and bed table properly.

n If you visit the bathroom or toilet, and you are concerned that it does not look clean report this immediately to the nurse in charge of the ward. Request it be cleaned before you use it, and use an alternative in the meantime.

n Your bed area should be cleaned regularly. If you or your visitors see something that has been missed during cleaning report it to the nurse in charge and request it is cleaned.

n Always wear something on your feet when walking around the hospital.

n Ask your visitors to wash their hands on arrival to the Ward.

Reference: Infection Control Nurses Association, 2004

Web site www.icna.co.uk


4 Preparation for your hospital stay

Pre Admission assessment clinic

You will be asked to attend a pre admission clinic which is run by specially trained nurses, you will be invited to a clinic at Prince Phillip Hospital Llanelli or at Glangwili hospital Carmarthen. At the appointment we will ask questions about your health and wellbeing to ensure that you are fit enough to have your surgery. You will also be informed of any special instructions that you must follow before your operation. This will include eating and drinking restrictions, medication advice and hygiene requirements.

Please be aware that:The appointment will last approximately one hour in the clinic but you will also be required to attend other departments for some of your tests.

You should bring

n A list of the medications that you take including over the counter and herbal medications

n Urine Sample

n Occupational Therapy measurement Form

n Joint Replacement Questionnaire

Some tests may also be done to make sure you are fit for surgery. These include:

n Blood tests

n Heart Trace (ECG)

n X-Rays

n Urine tests

n MRSA Swabs may be taken from your nose, throat and groin

You may need other tests and these will be discussed with you at the time. An anaesthetist may also see you or request you to return for review after your test results.


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Please inform the pre admission unit if:

n If you have any changes to your health social circumstances or medications

n There are any changes in your skin such as cuts, ulcer abscesses insect bites and rashes

n You have any signs of infection including dental problems

Occupational TherapistPrior to admission it is the aim that all patients are seen by the Occupational Therapy (OT) staff who will provide advice to help maintain your independence. Following your surgery there will be certain movements you need to avoid for 12 weeks to minimise the risk of damage or dislocation to your hip. This will include not sitting on furniture which is too low and not bending to dress your lower half. You will be given a form to complete and return to the pre-admission clinic which asks you to measure certain items of furniture in your home. This will establish whether you need equipment which the Occupational Therapy department will loan to you. They will also provide dressing aids. the movements you need to avoid (hip precautions) are as follows :

n Don’t cross your legs whilst sitting, standing or lying down

n Don’t turn or twist your operated leg in or out. When turning always make sure your feet are facing the same way as the top half of your body

n Don’t bend your hip joint further than a right angle (90 degrees) i.e do not reach down towards your feet and do not move your operated leg towards your chest

n Don’t sit for too long you may become stiff and find it difficult to stand from a sitting position

n Don’t drive until you have been seen and assessed at your outpatient appointment and gained consent to return to driving, this is usually 6 weeks and you will need to confirm with your car insurance company.

n Don’t walk without your walking aids until advisedn Don’t stand still for too longn Don’t overdo it

You will have an opportunity to practice daily activities whilst avoiding these movements during your admission with the therapy staff.

n Do Continue to take pain medication regularly

n Do the exercises as instructed by your physiotherapist


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n Do use a pillow between your legs when you are sleeping

n Do contact a member of the team if you have any concerns following discharge.

Help at home

It is likely that you will need help with some tasks once you return home. You will need help to wash your feet and to change anti-embolic socks (TEDS) and you may also need help with cleaning and shopping. Family members and friends are often the best sources of this type of help.

These arrangements must be made before you come into hospital.

If you do not have anyone to help you we can direct you to sources of information about getting assistance.

Joint School

You will be invited to attend an education session which we call Joint School. This session is based at Prince Phillip hospital Llanelli and will last approximately one hour. It is run by a specialist nurse with input from a physiotherapist and an theatre stadd as well as ward staff and aims to teach you about Hip Replacement and your recovery.

Each stage of your care will be explained to you so you have a thorough understanding of what to expect and you will have the opportunity to ask questions and discuss any concerns. It gives you the chance to meet other patients undergoing the same operation as yourself. You will be taught specific exercises to strengthen the muscles around your hip as well as being reminded of the precautions you will need to follow after your surgery.

If you have a friend or relative who is going to support you on discharge it may also be worthwhile for them to attend as it will provide a better understanding of your post-operative needs.

Please make every effort to attend because you will be given vital

information about your surgery and how you can help yourself to

make a good recovery.


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Before you come into hospital for surgery

1. What to do before you come to hospitaln Pack a small bag of clothes

n Leave your valuables at home as there is no facility to secure belongings on the ward

n Electrical items requiring mains supply are not permitted

n Ensure your domestic arrangements are in place ready for your return home before you come into hospital

n On the morning of your surgery will need to have a shower and wash your hair with an antispectic wash that we will provide for you. You will need to dry your hair, but please do not use any hair products, deodrants, perfumes or make-up as you will be asked to wash again.

2. What to bring?

n Hip Replacement Handbook

n Loose fitting day clothes to wear during your stay including underwear and trainers/ sturdy shoes. It is not uncommon for feet to become swollen in the days following surgery so please choose footwear that is adjustable (with laces or Velcro) or stretchy. Footwear should be clean and have a non-slip sole.

n Nightwear and lightweight dressing gown

n Wash bag containing toiletries and soap

n Towel and face cloths

n Dressing aids (“Helping Hand”) Long Handled Shoe Horn

n Books/magazines

n Small amount of money to cover purchases from the hospital shop

n Any regular medication

n Contact details of the person who will be driving you home.


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Contact between patients and their relatives

and friends

The visiting hours at Prince Philip hospital are 7-8pm Monday to Friday. On Bank holidays and weekends it is 2.30-3.30 and 7-8pm. In Glangwili Hospital Carmarthen it is 7-8.30pm Monday to Friday and weekends 2-7pm. There may be circumstances when relatives/friends cannot visit during these hours, please do not worry; discuss with the nurse in charge.

n Please show respect and consideration towards patients and staff whilst you are visiting.

n Patients may become tired and need to rest. Please remember that other patients may wish to rest or sleep during visiting hours.

n A patient should have no more than two visitors per bed at any time. We respectfully ask that your visitors do not sit on your bed or chair and if your relatives/friends are seen doing this please do not be offended when staff approach them. Chairs for visitors are provided and we would be grateful if they were returned to the appropriate place.

n Please nominate 1 family member to liaise with the ward for patient information as this releases the nurses to care for your relative more effectively.

n Flowers are not permitted to be brought onto the ward for patients because they are at risk of being knocked over and because the water has a potential to harbour and spread infection.

n Patients are seen by members of the team throughout the day and may be required to participate in physiotherapy exercise sessions or to be taken off the ward for x-ray during visiting hours. Visitors may be asked to wait while treatment occurs to encourage full participation by patients and to promote our patient dignity and privacy policies.

n Please remember there is a charge for car parking.


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Activity guidelines pre and post operative exercises

and goals

It is important to be as fit as possible before undergoing a total hip replacement. This will make your recovery much faster. Some exercises are shown below that you should start doing now and continue until your surgery. You should be able to do them in 15-20 minutes, and it is recommended that you do all of them three times a day. It is not harmful for you to do more. Consider this as a minimum amount of exercise prior to your surgery.

Also, remember that you need to strengthen your entire body, not just your leg. It is very important for you to strengthen your arms. You will be relying on your arms to help you get in and out of bed, chairs and to walk with sticks.

Stop any exercise that is too painful.

If you find these exercises difficult, build up to the suggested number GRADUALLY.

Pre-op Exercise Plan for Total Hip Replacement

1. Ankle pumps .............................................................. 20 reps. twice/day

2. Static quads (knee push-downs) ............................... 10 reps. twice/day

3. Arm chair push-ups...................................................... 5 reps. twice/day

4. Gluteal sets (buttock squeezes) ................................. 10 reps. twice/day

5. Inner range quads ...................................................... 10 reps. twice/day

6. Heel slides (slide heel up and down) ......................... 10 reps. twice/day

7. Arm chair push-ups...................................................... 5 reps. twice/day

(See following pages for these Exercises)


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Exercise No. 1

Ankle pumps

Move ankle up and down as far as you can go. Repeat 20 times.

Exercise No. 2

Static quads - knee

push-downs.

Press knee into bed, tightening the muscle on front of the thigh. Hold for 3-5 seconds.Do NOT hold your breath.Repeat 10 times.

Exercise No. 3

Gluteal sets - buttock

squeezes

Squeeze buttocks together and hold for 3-5 seconds. Do not hold your breath. Repeat 10 times.

Exercise No. 4

Inner range quads.

Lie or sit with a roll under the affected knee. Lift foot, straightening the knee and hold for 5 seconds. Do NOT raise your thigh off the roll. Repeat 10 times.


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Exercise No. 5

Hip abduction

(slide leg out and back)

Lie on your back, slide affected leg out to side. Keep toes pointed up and knee straight. Bring leg back to starting pointRepeat 10 times.

Exercise No. 6

Hip Flexion

(slide heel up and down)

Lie on couch or bed. Slide heel toward your bottom. Make sure you are reclined for this exercise. Repeat 10 times. REMEMBER the 90° rule! It is not the aim to bring your knee up to your chest.

Exercise No. 7

Arm chair push-ups

This exercise will help strengthen your arms for walking with a walking frame and then elbow crutches. Sit in an armchair place hands on the armrest, straighten arms, raising your bottom up off chair seat. Keep your feet on the floor. Repeat 10 times.


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After Discharge

n Continue to walk with sticks/elbow crutches

n Continue with your exercises as instructed

n Ensure that you follow precautions

n Normal stair climbing can resume at 6 weeks (appropriate)

n If you feel comfortable at 3 weeks onwards you can progress onto one walking stick used in the opposite hand to your operated leg. If it is not comfortable you can be progressed at clinic at 6 weeks.

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5 Hospital stay

Day of surgery

What to doMost patients are now admitted on the day of surgery and aim to go home within 3-5 days. Please go to the Ward as stated on your admission letter at the time stipulated.

You will be asked to stop eating food (including sweets and chewing gum) six hours before your operation. Please continue drinking non-fizzy water, plain squash, black tea or coffee (no milk) until two hours before your surgery. The nurses on the ward will tell you when you need to become ‘nil by mouth’ (depending on the approximate time of your operation). You may also be given special high energy drinks to take until

two hours prior to surgery.

What to expect - immediately prior to surgery

On the ward you will be admitted by a nurse who will recheck your details and carry out further assessments. You will be given 2 identity bracelets to wear. Your discharge will be discussed and a provisional expected date for discharge given to you. As part of the preparation for your surgery you will need to have a shower. You will be seen by a Doctor who will mark your limb and review your consent.

You will be seen by your anaesthetist and possibly your consultant. The anaesthetist will discuss the anaesthetic and your medical history with you. Sometimes the anaesthetist will prescribe a ‘pre-med’, which will help you to relax and/or help with pain control and nausea. When it is time for your surgery, you will be asked to change into a surgical gown and antiembolic stockings and you will be collected for theatre by a member of theatre staff. One of the nurses from the ward will then go through a check list with you and accompany you to the theatre reception where your care will be transferred to the theatre staff.

What to expect - immediately after surgery

At the end of the operation you will be transferred into the recovery room where you will be closely monitored. You will already be on your bed.


Your wound will be covered with a dressing and you may have:

n An oxygen mask or nasal cannulae

n A drain to the wound capturing excess blood

n A drip in your arm to help replace any fluids you may have lost during the operation

n Calf pumps on to aid circulation and reduce the risk of blood clot formation

n A blood pressure cuff on your arm which will monitor your blood pressure on a regular basis.

Thigh length white Anti-embolic stockings which will help to reduce the risks of blood clots forming and also assist with maintaining a good circulation.

Sometimes a tube will have been placed in your bladder (urinary catheter). This is only usually in place overnight and makes passing urine easier after the operation.

When the recovery nurses feel you are ready, you will be taken to the theatre reception to be collected by a member of staff from the ward. You will be encouraged to eat and drink as soon as you feel well enough.

Your physiotherapist will see you and commence you on your exercise regimen. You may be helped out of bed on the afternoon of your surgery and sat in the chair or walk a few steps with a walking frame this is dependent on the time you return from theatre.

Day 1 - after surgery

n In the morning you are expected to start the exercises in bed

n You will be assisted out of bed to sit in a chair by a nurse or a physiotherapist

n You will be encouraged to wash and change into your own day clothes

n Nursing staff will continue to carry out regular checks of your blood pressure throughout the day

n A doctor will see you to monitor your progress


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n The Physiotherapist will see you and progress your mobilisation. You will be reminded of hip precautions and how to keep safe during activities. You are encouraged to take painkillers regularly to enable you to move about comfortably, rather than to wait until you have pain, at least for the first few days

n If you have not been seen by the Occupational Therapist (OT) before your operation, an initial assessment will be made today

n You will be visited by a member of the pain team and a pharmacist to ensure that your pain is under control and that you are receiving all of your usual medication, you will be given regular pain relief medication by mouth. It is not uncommon for blood pressure tablets to be omitted for a day or two after surgery as blood pressure can be lower than normal at this time. Many of these medications can make you constipated and you will be offered laxatives to counteract this

n Throughout your stay please let the nurses know if you have not had your bowels open so they can address the problem

n It is important to tell staff if you are in pain or feel sick so that you can be given medication to control this

n If you have a drain this will be removed and your wound will be checked.

n If you are drinking sufficiently your drip will be discontinued and your urinary catheter will also be removed

n You will have bloods taken

n You will have an x-ray of your new joint.

Day 2The following days take a similar pattern with you becoming increasingly more independent with mobility and personal care tasks:

n You will be able to wash in the bathroom

n The Physiotherapist will continue to progress your exercises and your mobility. You will increase your walking distance. You will be progressed onto two walking sticks (sometimes elbow crutches are used)

n The occupational therapy staff will visit you to ensure that you are able to dress safely using your dressing aids. They will confirm that any equipment needed for home is in place


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n The nurse will check your wound and general health and discuss with you your discharge date. You will be visited again by the doctor’s looking after you.

DAY 3 onwardsDay 3 is similar to Day 2 in the morning.

n By now you will be walking with sticks and washing and dressing yourself with the dressing aids you have been given

n The physiotherapist will continue with your exercises, and progress your mobility with sticks and you will be taught to go up and down the stairs if you are ready

n The nurse will confirm your discharge arrangements and make arrangements for your discharge medication, he/she will also assess your wound

n The Occupational therapy staff willl ensure that you are able to complete all daily tasks in line with the hip precautions, this will include transferring on/off bed, chair, toilet and practising stairs/steps. Please see page 35 for further information

n If you have passed all the physiotherapy and occupational therapy requirements the nurse will let you know if you are able to confirm your discharge with the person providing your transport home.

Day of Discharge

You are going home todayn Your wound will be assessed by the nurse, it should be clean and dry

for 24hours before discharge. You will also be re-assessed and re-issued with another pair of stockings

n An appointment will be arranged with the district/practice nurse to visit you the day after discharge to check the wound and then to remove the clips or stitches around 10-14 days after surgery. You will be given a letter for the nurse, wound dressings, dressing packs and a clip remover. If you are unable to get to the GP surgery a District Nurse will be arranged instead

n Confirm your discharge with your next of kin


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n You will be given painkillers, anti-coagulants and your usual medications to go home with and a copy of the doctors letter, should you need to see them in the following week, which will have a list of your discharge medication should you require any more painkillers

n The physiotherapist will check that you are familiar and comfortable with your exercise regime

n The occupational therapist will confirm that you have the appropriate equipment and your discharge destination has not changed

n You will be given an outpatient appointment with your Consultant, Orthopaedic Specialist Nurse or Physiotherapist before your discharge. This will usually be six weeks folowing your surgery

n We aim to discharge you before lunchtime.

If You Have Questions at Anytime Please Ask the Staff - We are Here to Help‚


Following your stay

It is very important that you have organised the necessary support for when you return home. After major surgery you may feel that it is a good idea to ask friends or family members to stay with you or to help with simple chores. They will also be on hand to give you moral support as once you have left hospital you may feel isolated and uncertain of what to expect. You may also like to have one of your carers escort you home following your stay at Prince Philip Hospital and Glangwili Hospital and be fully involved in your care.

Some helpful hints to act as a guide This information is designed to help you through the transition from hospital to home but always follow any specific advice given to you by your Consultant or nurse.

Advice/Precautions for daily activities

Household jobsYou should avoid all strenuous jobs immediately after treatment. Only when you feel up to it, should you attempt small chores and even then, ideally, you should have somebody helping you. It is advisable not to vacuum or move furniture around for the first 3 months and not to try and clean your windows.

Washing / bathingYou should follow the specific advice given by the Therapy staff, which may include the use of specific aids. You will need to keep your wound dry for the first 2 weeks after the operation and you will be taught how to have a strip wash at the sink whilst in hospital. You are advised not to use the bath, or shower over the bath for 12 weeks after your operation. If you have a walk-in shower/cubicle you may use this when the clips or stitches are removed and the wound is healed.

Dressing InstructionsYou will be able to dress as appropriate to you after your operation.The Occupational Therapist will show you the safest method and supply gadgets if necessary that will help, e.g. Helping Hand and long handled shoehorn On discharge from hospital, you should continue to dress in the way taught by the Therapist for at least 12 weeks after your operation date.

6 Discharge planning


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Remember the following points:

n When dressing, sit on the side of the bed or in a suitable chair. This will help your balance

n Collect all the clothes you intend to wear and put them on the bed next to you before you start. Avoid twisting and overstraining to reach them

n Always dress your operated leg first and undress it last

n To put pants or trousers over your feet, use the helping hand to hold the waistband and lower the garment to your feet. Insert the operated foot first, repeat with the other leg before pulling right up. If necessary you will be provided with a gadget to put on your socks/stockings/tights

n DO NOT CROSS YOUR LEGS WHEN DRESSING

n Do not wear tight garments over the wound as it may cause discomfort

n Begin to wear shoes as soon as you start to move around. Always use the shoehorn

n Avoid twisting; pull clothes straight up or down

n You may need help to change your anti-embolism white stockings (TED’s). These are worn for up to 6 weeks following surgery.

Lying DownLying on your back for 12 weeks is the safest position for you to sleep in. If you have any concerns regarding this please discuss with your therapist.


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Getting in/out of bed

Transfer - Into Bed

WHEN GETTING INTO BED:

n Back up to the bed until you feel it on the back of your legs (you need to be halfway between the foot and the head of the bed) or position your bottom close to the pillows

n Reaching back with both hands, sit, down on the edge of the bed and slide your operated leg forward. Move your sticks out of the way, but keep within reach

n Move your bottom over towards the centre of the bed as far as you can

n Move your bottom around so that you are facing the foot of the bed

n Lift your leg into the bed while sliding around

n Keep sliding and lift your other leg into the bed

n Slide your hips towards the centre of the bed.

Transfer - Out of Bed

WHEN GETTING OUT OF BED:

n Sit up while lowering your un-operated leg to the floor

n Slide to the edge of the bed

n Use both hands to push off the bed

n Balance yourself before reaching for the frame or sticks.


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Sitting and StandingSit in the chair that has been recommended by the O.T. You should not sit for long periods but get up and walk around on a regular basis. Make sure that you can feel the chair behind your knees. Put your operated leg out in front of you. Take your hands off the sticks and put them onto the chair arms. Slide your operated leg forward as you lower yourself into the chair. To stand up from a chair, put your operated leg out in front of you. Push on the arms of the chair to raise yourself into a standing position before putting your hands onto your sticks.

ToiletMost toilets are a standard height of 15inches and for most people this will be too low. Your Occupational Therapist will assess this and may provide you with equipment which will make the toilet the correct height for you to use. Use the seat of the toilet or the arms of the frame you have been provided with to support you as you sit, remembering to slide your operated leg forward as you lower yourself down.


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Stairsn Always use a handrail if there is one

n Going up - lead up with the un-operated leg, followed by the operated leg and the stick/crutch

n Going down - lead down with the stick/crutch and the operated leg, followed by the un-operated leg. (A lot of people use this aide memoir – the good go up to heaven and the bad go down to hell!!!)

n Keep this method up until you feel strong enough to walk upstairs normally. Many patients can manage this between weeks 4-6 (a few stairs at a time).

CarDO NOT drive for the first 6 weeks, as you may not have full control of the car. It is advisable to check your cover with your insurance company after this period. However, it is possible to travel safely in a car as a passenger.

For comfort slide the seat back on its runners, recline the seat slightly to give yourself maximum legroom. It will be easier if the car is parked away from the kerb, so that you get into it on the level. To get into the car, turn your back to the seat and lower yourself into the seat, holding onto the door frame. Bring both legs in together, remembering not to twist your body. It is a good idea to put a cushion on to the seat to make it a little higher, and some people find putting a plastic bag on the seat helpful to slide into the seat. Your therapist will discuss this with you.

Kitchen activitiesThink about the tasks that you have to do in your kitchen before your operation. Rearrange your kitchen so things are at a convenient level, so you do not have to bend your hip more than 90 degrees. Do not stretch to reach high cupboards. If you have any concerns about managing meals, talk to your Occupational Therapist.


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Sexual activityDepending on the operation you have had you may be concerned about resuming sexual intercourse. You may request specific literature from the nursing staff prior to leaving hospital. Our clinical staff are very comfortable giving you this advice and do have some written material; unless you have been advised otherwise you should do what feels right for you. Sexual intercourse may be resumed with care as the non-active partner when you feel comfortable, usually around 6 weeks after surgery; taking into account your hip precautions.

Return to sport and leisuren Low impact sports such as golf, bowls, cycling and swimming may

normally be resumed after 3 months. Check with your consultant at your follow up appointment

n High impact sports, i.e. jogging, tennis, squash, jumping activities and football are not recommended therefore are participated in at your own risk.

WorkIt is best to feel completely recovered before you return to work. If necessary, go back only on a part time basis and then build up the hours gradually. Discuss this with your GP, or consultant at your following appointment as it depends on your type of work and you may need to have the 3 month period off work to comply with following your precautions.

Post-discharge telephone callYou will be contacted a few weeks after your discharge by a member of the orthopaedic team. This is to check on your progress and offer you advice should you need it. You will also be asked some questions which are the same as the scoring tool you completed before the operation this will provide us with an outcome for you surgery. However if you should experience any problems before being contacted please do not hesitate to contact us on 01554 783109/783108.


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Why have I still got swelling?

Healing tissues are more swollen than normal tissue. This swelling may last for several months. Ankle swelling is due to the fact that each time we take a step the calf muscles contract and help pump blood back to the heart. If you are not putting full weight on the leg, the pump is not as effective and fluid builds up around the ankle. By the end of the day lots of people complain their ankle is more swollen.

What can I do about it?

When sitting the ankle pump exercises work the calf muscles and help pump the fluid away. Try to put equal weight through each leg and “push off” from your toes on each step (those patients who have been told to limit their weight bearing cannot do this). Have a rest on the bed after lunch for 1 hour. Cushions under the foot of the mattress or bricks under the legs at the bottom of the bed will mean that gravity will help drainage.

Why is my scar warm?

Even when the scar has healed there is still healing going on deep inside. This healing process creates heat, which can be felt on the surface. This may continue for up to six months. This is different warmth to that of an infection.

Why do I get pain lower down my leg?

The tissues take time to settle and referred pain into the shin or behind the knee is quite common.

Why do I stiffen up?

Most people notice that whilst they are moving around they feel quite mobile. After sitting down the hip feels stiff when they stand and they need to take 3 to 4 steps before it loosens up. This is because those healing tissues are still swollen and are slower to respond than normal tissue.

Is it normal to have disturbed nights?

Yes, very few people are sleeping through the night at six weeks after the operation. As with sitting you stiffen up and the discomfort then wakes you up. Also many people are still sleeping on their backs, which is not their normal sleeping position so sleep patterns are disturbed. You may sleep on your un-operated side after 6 weeks. Most people find it helpful to have a pillow between their legs.

7 Frequently asked questions


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I have a numb patch - is this okay?

Numbness around the incision is due to small superficial nerves being disrupted during surgery. The patch usually gets smaller but there may be a permanent small area of numbness.

Why does my joint click?

This is normal and it is usually a sign that those swollen tissues are moving over each other differently than before. You should not let this worry you, as again this should improve as healing continues.

When should I stop using a stick?

Stop using the stick when you can walk as well without it as with it. It is better to use a stick if you still have a limp so that you do not get into bad habits that are hard to lose. Limping puts extra strain on your other joints especially your back and other leg. Use the stick in the opposite hand to your operated hip.

Many people take a stick out with them for 3 to 4 months after the operation as they find they limp more when they get tired.

How far should I walk?

This varies on your fitness and what your home situation is. You should feel tired not exhausted when you get home, so gradually build up distance, remembering you have to get back.

Will I set off the security scanner alarm at the airport?

Most joints are made of stainless steel and these may set off the alarm. You will be given a card on discharge which has the date of surgery and type of joint replacement written on to it which is suitable to show at airports.


8 Your diary and notes

Your diary

Many patients have questions and comments they wish to make regarding their stay but because of distractions forget to ask. It can be helpful to keep a reflective diary. This diary can be used to help prompt you to remember information in order to complete your patient questionnaire or to ask questions of the nursing staff:

Preoperative day:

Day of operation:

Postoperative day 1.





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Keep-in-touch List Name: Phone:

Address: Type of Surgery:

Name: Phone:


Name: Phone:


Name: Phone:


Name: Phone:


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Your questions and comments page

Notes to the patient:

A member of the Prince Philip Hospital and Glangwili Hospital staff will telephone you a few weeks after discharge. The following aide memoir is for you to use to make notes of questions or problems you may wish to speak to them about and to note the answers you receive.

Questions I would like to ask The answers I received

Q1. A1.

Q2. A2.

Q3. A3.

Q4. A4.

Should you wish to telephone Prince Philip Hospital and Glangwili Hospital with a query, before or after our member of staff telephones you, it may be helpful to make a note of the date and to whom you spoke to:

I telephoned on (date)

I spoke to (name)


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Complaints and compliments

we would like to hear your views about your experience of our services. Our aim is to provide you with the highest standards of care at all times, but we recognise that things can sometimes go wrong.

If you have any concerns, speak to the ward sister or senior therapist who will be able to assist and, hopefully, resolve matters to your satisfaction. Where this is not successful, ask for our leaflet “If things go wrong – a guide to our Complaints Procedure”. This advises you how to make a formal complaint and the various stages of the procedure.

In making a complaint, advice and assistance is available to you from your local Community Health Council, which represents the interests of patients and the public in the NHS. The Community Health Councils are skilled in handling complaints. Their Complaints Advocates can provide a range of support during the process of your complaint.

Your local Community Health Council can be contacted as follows:The Chief Officer Carmarthenshire CHC 103 Lammas Street Carmarthen SA31 3APTel: (01267) 231384

The Chief OfficerPembrokeshire CHCSuite 2, Cedar CourtHavenshead Business ParkMilford HavenPembrokeshire SA73 3LSTel: (01646) 697610

The Chief OfficerCeredigion CHC8 Portland RoadAberystwythSY23 2NLTel: (01970) 624760


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Copyright Notice

This booklet and all content, artwork, photographs, names, logos andmarks contained on and/or with and/or in it (together “Content”) areprotected by copyright, trade marks and other rights of intellectualproperty owned by Prince Philip Hospital and Glangwili Hospital and Stryker UK Ltd. or licenced to it. The user is entitled to view any part of this booklet.However, the Content must not be used nor reproduced (in whole or inpart) for any other purpose or for direct commercial gain. A patient education initiative provided by Prince Philip Hospital and Glangwili Hospital supported by

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